Managing patients with symptomatic coronary and carotid artery disease.

The management of patients with concurrent carotid and cardiac disease remains enduringly controversial. National and international guidelines provide no real consensus, and there is poor-quality natural history data to inform the debate. Systematic reviews suggest that coronary artery bypass grafting (CABG) plus either staged or synchronous carotid endarterectomy (CEA) or carotid artery stenting (CAS) are associated with a 9% risk of procedural stroke or death. Given that about 90% of these procedures are performed in asymptomatic individuals, it is questionable whether any benefit is actually being conferred to the patient. A few contemporary studies have now shown that the risk of stroke in neurologically asymptomatic patients with a unilateral 70% to 99% stenosis undergoing an isolated CABG is extremely low. These data, therefore, challenge current practice and mandate a radical review of evidence and guidelines.